Donna discussed managing when a serious incident occurs; she discussed what should be done in the immediate aftermath of an incident.

Decisions made in the wake of a serious incident are critical to the success of how the next days, weeks and months play out. Key steps to success are; disaster plans and systems, leadership, practice. Immediately action in the aftermath should include:

Call for help

Communicate

Report

Secure

Donna went on to discuss carrying out a Root Cause Analysis saying; “the whole idea of RCA is to learn and to stop it happening, not to apportion blame”, she discussed steps to an effective RCA and how to get started.

Donna said; “A key issue is talking and listening to the people involved. The patient and families are an enormous resource in investigating.”

Donna went on to discuss contributory factors, root causes, systems for gathering information, and quality improvement based on the findings.

Donna’s full presentation is available for download at the end of this page.

Donna began her career as a Physiotherapist and held Superintendent and clinical supervisory positions as a musculoskeletal specialist. In 1998 she qualified as a Chartered Safety Practitioner, introducing and embedding whole systems risk management into an Acute Trust.

Whilst at NPSA from 2003 Donna’s roles included Head of NRLS Reporting and Head of Investigation and Training. She has worked collaboratively with the World Health Organisation since 2007 as an expert adviser on event analysis, and has co-authored internationally recognised guidance and chapters on good practice in healthcare investigation. In 2010 Donna completed air accident investigation training at Cranfield University. More recently she has worked with peers to develop a not for profit training and advisory organisation ‘Patient Safety Science’, and led development of the world’s first ‘Investigation Branch’ for health at NHS England.